The Resistance Issue

In my first post on antimicrobial resistance, I provided a brief overview of issue and why the it merits concern. In the second, I discussed how resistance develops as a result of selection pressure on a population. In this post I would like to address some of the reasons why antimicrobial resistance is a growing problem, and highlight some of the issues we face in trying to solve this problem.

Now, think back to my first post on antimicrobial resistance and consider how much we rely on antibiotics, not just in medicine, but also in agriculture. Every single time that a person or animal goes on a course of antibiotics, that creature essentially becomes a proving ground for the entire bacterial population that exists within the individual. The bacteria that are strong enough to survive the drug will eventually flourish, while those that are weak will die off. If we were only using antibiotics sparingly to deal with serious illness or infection, then this would not be such a problem. Resistance could still develop, but the likelihood of it happening would be relatively low. Instead, however, our culture has taken to using antibiotics to treat any cold or sickness, whether warranted or not. We use it constantly for surgery, whether it be a critical operation to remove an appendix before it ruptures, or for cosmetic surgery to alter the shape of someone’s nose. Furthermore, we feed it to livestock animals on a daily basis as a preventative measure…a measure, I will point out, that is only required because of the conditions in which the animals are being raised. Based on data from the FDA that was collected for 2009, 80% of all antibiotics (by weight) that are used in the US are given to livestock animals.

This is a pretty serious issue, in my opinion, and not an easy situation to resolve. Oh, the answer is certainly simple enough: “We should stop giving antibiotics to livestock.” That is very easy to say, and in theory should be easy enough to do, but in practice I think it is going to be very difficult. There are many facets that must be considered, but I think that we can narrow the main issues down to three basic points, all of which are interrelated: economics, politics, and culture.

The economics of the situation follow the reasoning of a free market economy. Granted, we do not have a completely free market, but for the sake of this discussion, let us pretend that we do, and that our market is ruled by the laws of supply and demand. In general, when there is a demand for a product, industrious persons will attempt to supply that product in order to make money. In other words, people who want to eat meat are willing to pay for it, and so farmers or ranchers will provide it. This leads to competition among the suppliers, who historically have found that it can be more profitable to raise very large herds or flocks, as opposed to just a few animals at a time. This led to industrialization. There is a limit to how many animals you can graze on a plot of land, so you must find ways to squeeze more animals into a smaller space. This leads to health issues. Rather than risking an infection wiping out half of your animals, you instead supply them with cheap antibiotics as a preventative measure. This is not done to be evil, or out of malice, but because that is how the industry can remain profitable. This happens because people have limited budgets, and given the choice between $3 per lb for ground beef at the grocery store as opposed to anywhere from $6 to $10 per lb for local, grass-fed, antibiotic-free, hormone-free beef, the choice is often obvious for most people. This relates to our culture as well, as I will discuss later, but the fact is that as long as people are willing to pay for cheap meat or animal products, there will be industries that strive to supply it. So there are economic factors driving the large-scale use of antibiotics in agriculture.

There are other economic factors at play as well, related to the drug development side of the equation. One solution to the antibiotic resistance issue might simply be to develop more antibiotics, right? Simple solution, but not easily accomplished. Many antibiotics that we use share similar mechanisms of action, so if a bacteria develops resistance to one, it will likely also be resistant to other similar drugs as well. In other cases, the mechanism of resistance itself is very general, and makes the bacteria resistant to broad spectrum of different antibiotics. Scientists must get creative to develop drugs that are safe for humans and animals, but deadly for microbes. This requires a lot of time and money, but where does that money originate? Money usually comes from either public funds (the portion of your tax dollars that go to support research) or private investment (think drug companies). The problem is that public funding for research depends on government allocation of tax revenue, and our economy has been suffering for a while now. Private funds, on the other hand, come with the expectation of a return on the investment, and antibiotics are not the best financial investment. It costs a lot to develop them, but people only use them sporadically, unlike drugs used to treat high blood pressure, cholesterol, joint pain, mental disorders, etc. Such drugs are usually prescribed and taken for years, or even for the remainder of an individual’s life. Drugs like this result in a serious return on your investment. Antibiotics do not. You take them for a week and you are done. If the antibiotic is too expensive, then the patient elects to take something else. This means that there are economic factors affecting the discovery of new antimicrobials as well

The politics of the situation are no less complicated. We do not live in a completely unregulated economy. In theory, our government strives to protect us by regulating industries to protect our health and shared resources. Federal agencies make sure that food is properly processed and not contaminated, that waste is disposed of properly, that pollution is minimized, etc. There will always be unscrupulous people who are willing to put your health at risk, exploit a shared resource, or whatever in order to protect their interests or turn a profit. If you are not familiar with the concept “the tragedy of the commons”, here is an article that you might want to read. However, given the nature of our political system, as an industry becomes larger and gains for financial power, it can in turn influence regulation through lobbying and campaign contributions. As such, it can be very difficult to effectively regulate “the meat industry” or “the dairy industry”. Even more challenging is how to regulate large-scale production of meat and animal products without stifling the ability of small farms and local growers to supply such products. Besides, as you might have noticed, our government is not exactly functioning at peak efficiency or with particularly high levels of cooperation these days. So we are left with a situation where it is challenging to regulate the industries that are responsible for using antibiotics on such a large scale, while at the same time the act of trying to regulate such industries makes it difficult for small-scale producers to compete.

More important, I think, than either the economic or political factors at play here is our culture. Meat is a staple part of our average diet in the U.S., and the cost of meat in our country is among the lowest in the world. For an interesting look at how our food prices compare to other countries, take a look at this slideshow. What is striking to me is that we tend to fall somewhere in the middle for almost everything, from coffee beans and bananas to eggs and potatoes. We are the lowest, however, for meat (ground beef and chicken, in the slideshow). It should come as little surprise that Americans are also among the top consumers of meat in the world. In America, and certainly other places as well, I think that we have gone beyond simply enjoying the relative abundance of low-cost food, and come to expect it. Have you ever spoken to your grandparents or great-grandparents about their childhood, what they ate, and how they lived? This was not always the case in our country. Our culture has changed from one in which meat composed a relatively modest portion of our diets to one in which it is a central component of our diet. Whether you think this is a bad thing or good thing, in my opinion it is one of the largest challenges that we must overcome if we are to have any hope of reforming our agricultural practices and slowing the rate at which antibiotic resistance develops.

This is why I stress that all of these problems are interrelated, with our culture at the heart of the issue. If people are willing to pay for cheap meat at the store, pay for cheap meat in the form of fast food, serve cheap meat in school lunches, and so on, then a demand for the product will continue to exist and someone will attempt to supply it. If demand remains so high that there exist industries capable of influencing legislation and regulation, then there will exist very little political will to make such a change happen. If economic factors make the discovery of new antibiotics unappealing, and federal funding for research does not increase, then the rate of discovery will not increase. Perhaps if we were confronted with a massive epidemic that threatened the lives of millions, we would be sufficiently motivated to effect such a change politically, or economic forces would swing in favor of drug discovery, but either way, the response would be too late. Discovering and implementing new drugs takes time. Years, if not decades. Legislation would have to focus on treatment and containment, as the resistant disease would already exist. Prevention would not be the main issue. The reality is that this problem is growing gradually, and thus is more difficult for the average person to see. Many of the same arguments that have taken place regarding climate change can be applied here as well. The changes are not dramatic and sweeping, but instead happen gradually over time. We will not wake up tomorrow and find that all antibiotics have failed us. Instead, we will wake up to learn that a few more people are contracting resistant infection, and a few more people die as a result.

So what do we do? While regulating the use of antibiotics and the meat industry would be a big help, I am just not confident that it will actually happen in a meaningful or timely fashion (though I would love to be proven wrong). I think that our culture is going to have to change, and that is a truly challenging prospect because it means that we as a society must embrace the idea and make changes to our lives. Cutting antibiotics out of our lives, except in emergencies, is one thing. I have focused on the affects of agricultural overuse, but we also overuse them in our daily lives. It means enduring the occasional sinus infection. It means that you do not dose your kids with amoxicillin every time they get a runny nose. It means that doctors must tell their patients “no”, and patients must also be willing to tell doctors “no”. It means that we might want to consider having discussions about the value of elective, cosmetic surgeries, and whether they contribute to the problem. It means that we change our eating habits and vote with our wallets by refusing to support products (like meat) that were produced using antibiotics. For many, it means eating less meat as a part of their regular diet. It means finding ways to return to a more locally-oriented system of food production. It means giving up some of our luxuries to accommodate a higher cost for food. It means pressuring our legislators to change laws and regulations. At the heart of it all, it means that we must 1) take the time to be more informed and understand such issues instead of just being slacktivists and clicking a “like” button, and 2) take accountability as members of our society and begin to effect the changes in our lives that are needed to deal with this very real problem.